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April 17, 2019

Anatomic Relationship of the Complex Tricuspid Valve, Right Ventricle, and Pulmonary Vasculature: A Review

Author Affiliations
  • 1Department of Medicine, Division of Cardiology/New York Presbyterian Hospital, New York-Presbyterian/Columbia University Medical Center, New York
  • 2Brigham and Women’s Hospital Heart and Vascular and Lung Center, Harvard Medical School, Boston, Massachusetts
  • 3San Raffaele University Hospital, Milan, Italy
  • 4CARIM School for Cardiovascular Diseases, Maastricht University Medical Center/Maastricht University, Maastricht, the Netherlands
JAMA Cardiol. 2019;4(5):478-487. doi:10.1001/jamacardio.2019.0535
Key Points

Question  What are the anatomic, physiologic, and hemodynamic determinants of progressive tricuspid regurgitation?

Findings  In this narrative review, the complex relationship between the tricuspid valve apparatus and structure and function of the right side of the heart are described, as well as pulmonary vascular hemodynamics, starting with the anatomic construct, which determines these interactions. Abnormalities of any component can lead to a cascade of events that result in progressive tricuspid regurgitation.

Meaning  Understanding the pathophysiology of tricuspid regurgitation gives insight into clinical outcomes and the timing of interventions.


Importance  Severe functional or secondary tricuspid regurgitation (TR) is associated with poor long-term outcomes in natural history studies as well as specific disease states. An understanding of the physiologic causes of the TR is lacking precluding a systematic approach to treatment.

Observations  The complex anatomic relationship between the tricuspid valve apparatus and structure of the right side of the heart lends insight into the functional changes seen with secondary TR. The association of these changes with changes in pulmonary vascular hemodynamics can lead to a cascade of events that result in disease progression.

Conclusions and Relevance  Appreciating the role of pulmonary vascular hemodynamics on right ventricular and tricuspid valve morphology and function improves our understanding of the pathophysiology of secondary TR. The limitations of current therapeutic approaches for secondary TR have stimulated interest in improving outcomes with this morbid disease. Changes in timing or approach to intervention require a more comprehensive understanding of the pathophysiology.

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